Morning Report: 7/11/2013

First Morning Report of the new academic year is presented by Dr. Aluisio!

Tranexamic Acid (TXA)

What: Synthetic amino acid derivative of lysine that inhibits fibrinolysis by competitively inhibiting plasminogen (a TPI that prevents fibrin degradation).

How: 1000 mg in 100cc NS over 10 minutes followed by 1000 mg in 500 cc NS over 8 hours.

Who: Any blunt or penetrating trauma patient that presents within three hours of injury who requires or could potentially require blood products for resuscitation.

Why: Independent of blood pressure, GCS or injury type treatment with TXA significantly reduces 28-day mortality:

All cause by 9% (RR=0.91; 95% CI: 0.85-0.97; NNT=68)
Due to bleeding by 15% (RR=0.85; 95% CI: 0.76-0.96; NNT = 119)
Due to bleeding if treated within 1 hour from injury 32% (RR=0.68; 95% CI: 0.57-0.82; NNT = 41)
Due to bleeding if treated between1-3 hours from injury 21% (RR=0.79; 95% CI, 0.64-0.97; NNT = 77)

-In high-income settings with developed trauma systems the mortality reduction is likely better: 37% in subgroup analysis (RR = 0.63; 95% CI: 0.42-0.94).

-If administered beyond three hours from time of injury relative risk of death due to bleeding increases (RR=1.44; 95% CI: 1.12-1.84).

-It is safe and does not increase the risk for MI, stroke, DVT or PE.

-It is cheap ~$100.00 for a treatment course.

References:

1.) CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32.

2.) Roberts I, Shakur H, Ker K, et al. Trial collaborators. Antifibrinolytic drugs for acute traumatic injury. Cochrane Database Syst Rev. 2012;12:CD004896.

3.) Guerriero C, Cairns J, Perel P, et al,. Cost-effectiveness analysis of administering tranexamic acid to bleeding trauma patients using evidence from the CRASH-2 trial. PLoS One. 2011 May 3;6(5):e18987

4.) CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomized controlled trial. Lancet. 2011 Mar 26;377(9771):1096-101, 1101.e1-2.